Unit II: Reproduction Scrotal Pathology Ravin Bastiampillai, PGY-3 Division of Urology Original...
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Transcript of Unit II: Reproduction Scrotal Pathology Ravin Bastiampillai, PGY-3 Division of Urology Original...
Unit II: Reproduction
Scrotal PathologyRavin Bastiampillai, PGY-3
Division of Urology
Original slides made by Laura Nguyen (PGY-5)
Disclosure
You may only access and use this PowerPoint presentation for educational purposes. You may not post
this presentation online or distribute it without the permission of the author.
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
4232 List the differential diagnosis of scrotal pain
4221 Define the terms: varicocoele, hydrocele, spermatocoele,
epidymal cyst, acute orchitis, acute epididymitis and testicular
torsion and compare and contrast their clinical presentations
4223 Diagnostic tools and treatment options for varicocoele, hydrocele,
spermatocoele, epidymal cyst, acute orchitis, acute epididymitis
and
testicular torsion
Objectives
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
4225 Pathogenesis of testicular torsion and complications
4226 Recognize the need for urgent management of testicular torsion
4303 Describe pathogenesis of orchitis and epididymitis
4304 Describe the causes and diagnosis, treatment and complications
of orchitis and epididymitis
Objectives
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
4227 Prevalence and risk factors of testicular cancer
4228 Pathophysiology of testicular cancer
4229 Treatment options for testicular cancer
4230 Outline post-cancer care and support
4231 Impact of testicular cancer on biopsychosocial factors
Objectives
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
Anatomy
Clinical approach to scrotal masses
Scrotal masses
Acute scrotal pain
Testicular cancer
Outline
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
Anatomy
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
Anatomy
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
• Painful vs. Painless
• Benign vs. Malignant
• Etiology varies with age• Differential diagnosis differs between adults and children
Clinical Approach to Scrotal Masses
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
Clinical Approach to Scrotal Masses – HISTORY
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
• Age of patient
• History of Present Illness• OPQRST• Painful v. Painless• Lower urinary tract symptoms
• Past medical history, Family history, past surgical history
• Risk factors: infections, instrumentation of the urinary tract, congenital anomalies, prior history of neoplasm, trauma (recent and past)
Clinical Approach to Scrotal Masses – PHYSICAL EXAM
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
Vital signs: Temperature Abdominal and inguinal exam:
Hernias, lymph nodes, masses
Penis: Skin changes, masses, circumcised
Scrotum (supine and standing)• Skin
• Testes:
• Normal = 3.5cm long, 12-20cc volume
Hydrocele, varicocele, rashes, masses
Digital rectal exam
Differential Diagnosis
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
PAINFUL– Trauma
• Contusion, rupture
– Epididymo-orchitis
– Hernia
• Incarcerated, strangulated
– Torsion
• Testes
• Appendages
PAINLESS – Tumour
• Intratesticular
• Paratesticular
– Scrotal wall pathology
• SCC, sarcoma
– Varicocele
– Hydrocele
– Spermatocele
– Epididymal cyst
– Hernia
Differential Diagnosis
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
PAINFUL– Trauma
• Contusion, rupture
– Epididymo-orchitis
– Hernia
• Incarcerated, strangulated
– Torsion
• Testes
• Appendages
PAINLESS – Tumour
• Intratesticular
• Paratesticular
– Scrotal wall pathology
• SCC, sarcoma
– Varicocele
– Hydrocele
– Spermatocele
– Hernia
MALIGNANT
VARICOCELES
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
• Dilation of the veins of the pampiniform plexus of the spermatic cord due to absent competent venous valves in the spermatic vein
• 15% of males 30% of subfertile males
• Elevated intratesticular temperature seems to be the most plausible and widely accepted hypothesis
• Most are left-sided, may be bilateral. Be suspicious of a right-side-only varicocele
• Rare prior to puberty
VARICOCELES
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
History: • Painless v. throbbing pain; pain worse at night• Discomfort increases with activity/standing• Aggravated with Valsalva• Infertility
Diagnostic Tools:
1. Examination:• “Bag of worms”,“vascular thrill”
• Grade I: Palpable with Valsalva• Grade II: Palpable without Valsalva• Grade III: Visible • Abdominal mass
1. Scrotal ultrasoundThe finding of a varicocele by ultrasound only (i.e., not palpable
on physical examination) does not require intervention.
VARICOCELES
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
Indications for surgical intervention: Clinically palpable AND One of:
o Infertilityo Symptomatic o Adolescent varicocele
Surgical options: Retroperitoneal Inguinal Subinguinal Laparoscopy Transvenous embolization
HYDROCELES
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
• A collection of serous fluid in some part of the processus vaginalis, usually the tunica
• More common in childhood
• 1% of adults
• Congenital:• Processus vaginalis does
not completely close after testicular descent
• Acquired: • Primary (idiopathic) v.
Secondary (testicular disease)• Lymph: defective absorption, increased
production, lymphatic obstruction
HYDROCELES
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
History: • Painless (unless large)
• Variation during the day (suggests communication)
• Other symptoms (secondary hydrocele)
HYDROCELES
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
History: • Painless (unless large)
• Variation during the day (suggests communication)
• Other symptoms (secondary hydrocele)
Examination:• Transillumination
• Testis palpable?
Investigations/Diagnostic Tools:• Scrotal ultrasound
HYDROCELES
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
Treatment: • Adults:
• Symptomatic
• Cosmetic
• Underlying testicular pathology
• Children:• Most resolve within the first year of life
• If persists, may indicate presence of a hernia
Specifics:• Surgical (inguinal vs. scrotal)
• Aspiration
• Sclerotherapy
SPERMATOCELES
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
• Painless mass containing sperm
• Post puberty
• Common between 40 and 60 years, 30% of males
• Region of caput
• Usually can palpate the testis
separately from the spermatocele
• Dilation of an epididymal tubule,
does not affect transport of sperm
• Mass may transilluminate
• Difference from epididymal cyst
SPERMATOCELES
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
Diagnostic Tools/Investigations:
• Subjective and objective examinations
• Ultrasound
Treatment:
• Conservative
• Spermatocelectomy (surgical removal)
• Surgery may have adverse consequences so avoid this option if fertility is still desired
EPIDIDYMAL CYSTS
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
• Anechoic structure, sometimes palpable found by the patient,
physician or by ultrasound
• Clinically difficult to differentiate between a spermatocele and
an epididymal cyst
• Etiology unknown
• Treatment: Same approach as for a spermatocele
ACUTE ORCHITIS, EPIDIDYMITIS, EPIDIDYMO-ORCHITIS
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
History:
• Insidious onset
• Fever
• Recent instrumentation
• Sexual activity
• LUTS
Examination:
• Painful epididymis +/- testis
• Testis in normal position
• Urethral discharge
• + Prehn’s sign
ACUTE ORCHITIS, EPIDIDYMITIS, EPIDIDYMO-ORCHITIS
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
Diagnostic Tools/Investigations:
• CBC
• U/A, C&S, urethral swab for GC / Chlamydia
• Ultrasound
• Tuberculosis
KEY POINT: May resemble torsion! Ultrasound will indicate
whether arterial and venous flow is present
ACUTE ORCHITIS, EPIDIDYMITIS, EPIDIDYMO-ORCHITIS
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
Etiology• <35 years: N.gonorrhea,
C.trachomatis, E.coli• >35 years: E.coli• Mumps:
• 30% of patients with mumps• Risk of infertility
Treatment• Rest• Analgesics / Anti-inflammatories• Scrotal support
Antibiotics:GC: •ceftriaxone 250 mg IM•Cipro 500 mg PO
Non-GC:•Azithromycin 1 g PO•Doxycycline 100 mg BID x 7 days
E.coli:•Antibiotics IV if severe•Fluoroquinolone x 10-14 days
Complications: Abscess, Chronic pain, Venous thrombosis,
Epididymitis progressing to orchitis
TESTICULAR TORSION
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
Why is the diagnosis of torsion so important?
• Risk of testicular loss! ** 6 hours from onset of pain **
• >97% salvage if <6 hours, <10% if >24 hours
• Hormonal and fertility problems if contralateral testicular involvement
• Necrosis/Abscess
TESTICULAR TORSION
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
Extravaginal vs. Intravaginal Torsion
TESTICULAR TORSION
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
EXTRAVAGINAL•Pediatric/neonatal population only
•Complete torsion of the spermatic cord before the tunica vaginalis fuses to the dartos
History/Physical:
• Indurated testis, scrotal erythema, +/- edema
• Often asymptomatic, may be associated with a hydrocele
Diagnostic Tools:
• Clinical examination
• Ultrasound
• Surgical exploration +/- removal
TESTICULAR TORSION
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
INTRAVAGINAL
History:
• Acute pain at rest, with activity or during the night
• Nausea and vomiting
• History of ipsilateral pain
• 12-16 years (higher incidence), 85-90% of intravaginal torsions occur after age 10, but can affect any age group
Examination:
• Patient in pain
• Tender, erythematous, swollen testicle
• High riding, transverse lie
• Absent cremasteric reflex
• Bell-clapper deformity
TESTICULAR TORSION
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
INTRAVAGINAL
TESTICULAR TORSION
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
INTRAVAGINAL
Diagnostic Tools/Investigations: Subjective and objective examinations +/- Urinalysis +/- Ultrasound
o Duplex Doppler
Treatment: If suspected clinically, surgical
exploration is indicated Orchiectomy Orchiopexy bilaterally
TESTICULAR TORSION
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
TORSION OF THE APPENDAGES
•Torsion of the appendix testis (Mullerian remnant) or the appendix epididymis (Wolffian remnant)
•Local tenderness, blue dot sign
•Self-limited, supportive care
TESTICULAR CANCER
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
• 1-2% of cancers in males in the United States; incidence 5/100,000
• Age at presentation: childhood, 30-34 years and 60 years+
• Over 90% of tumours are intratesticular, 2-5% with extratesticular presentation
• Most common neoplasm in males20 to 40 years
TESTICULAR CANCER
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
Clinical Presentation:• Painless testicular mass
• Rarely painful (hemorragic cancer)
• Hydrocele
• Gynecomastia (5%)
• 10-30% with metastatic cancer (supraclavicular lymph node, difficulty breathing, low back pain)
Investigations:• Subjective and objective examinations
• Ultrasound
• Chest film
• Testicular markers: AFP, HCG, LDH
• Blood tests: liver function, CBC, creatinine, urea
• CT Scan
TESTICULAR CANCER
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
Risk Factors:• Cryptorchidism• HIV• Intratubular germ cell neoplasia• Family history of testicular cancer• History of testicular cancer (ipsi and/or contralateral)• Infertility• Gonadal dysgenesis
NOT ASSOCIATED WITH TESTICULAR CANCER:• Trauma• Microlithiasis
TESTICULAR CANCER
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
TESTICULAR CANCER
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
STAGING:
STAGE I•confined to the testis
STAGE II•involves the testis with metastasis to the retroperitoneal lymph nodes
STAGE III•involves the testis, with metastasis beyond the retroperitoneal lymph nodes
TESTICULAR CANCER
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
SEMINOMA
•50% of testicular tumours in adults
•Elevated BHCG in 10% of cases, all other testicular markers are negative
Treatments:
•Radical orchiectomy
•Pathology and staging of cancer will determine treatment approach
• Observation (stage IA-IB)
• Chemotherapy or radiation therapy (stage IB,IS, IIA, IIB)
• Chemotherapy (IIC, III)
TESTICULAR CANCER
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
NON-SEMINOMA
•Age of presentation and marker status varies based on histology
•Treatment:• Radical orchiectomy• Pathology and staging of cancer will determine treatment approach
• Observation (Stage IA-IB)• Dissection of retroperitoneal lymph nodes (IB-IIB)• Chemotherapy (IS, IIC, III)
• RADIATION THERAPY IS NEVER AN OPTION FOR NONSEMINOMA TUMOURS
TESTICULAR CANCER
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
AGE AFP B-HCG
Embryonal (15-20%) 25-35y + +
Yolk Sac tumour <2y + N
Choriocarcinoma (<1%) Histologic component of syncytiotrophoblast and cytotrophoblastAggressive, metastases
20-30y N +
Teratoma (5-10%) 25-35y N N
Mixed (40%)Histology: endoderm, mesoderm and/or ectodermRESISTANT TO CHEMOTHERAPY AND
RADIATION THERAPY
varies
TESTICULAR CANCER
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
GONADOBLASTOMA
•Benign tumour, rare, present only with gonadal dysgenesis•Treatment: bilateral orchiectomy since 60% of these tumours will undergo malignant transformation
LYMPHOMA
•most common bilateral tumor, often in older age group•Treatment: orchiectomy for pathology, treatment with chemotherapy
TESTICULAR CANCER
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
WHAT HAPPENS AFTER DIAGNOSIS AND TREATMENT?
•Follow-up• Varies depending on pathology and treatment• Urologist, Oncologist, Radiation Oncologist• Every 3 months for the first year• Blood tests (tumour markers, liver test, renal function)• Chest film and CT Scan of the abdomen and pelvis
•Support• http://testicularcancercanada.ca/index• http://oneball.ca/• Social worker
TESTICULAR CANCER
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
WHAT HAPPENS AFTER DIAGNOSIS AND TREATMENT?
•Biopsychosocial impact• Fertility• Self-image (implant)• Education (torsion, trauma, testicular pain)• At risk for cancer in the contralateral testicle (2-5% risk 15 years
post orchiectomy)• SELF EXAMINATION
POINTS TO REMEMBER
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
• Scrotal mass• Anatomy is key• Painful versus Painless• Testicular torsion Urological emergency!!
PRATICAL POINT• Learn how to perform a thorough examination of the male
reproductive system
Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai
Thank you!
Questions or comments?
Ravin Bastiampillai, PGY-3